Knee Immobilizers Are Not Appropriate for Managing Contractures or Spasticity
A knee immobilizer should not be used to manage contractures or spasticity, as immobilization worsens these conditions rather than treating them. The fundamental principle in managing spasticity and contractures is maintaining joint mobility through active range-of-motion exercises, not immobilization.
Why Immobilization Is Contraindicated
Immobilization promotes contracture formation and worsens spasticity by increasing reflex hyperexcitability. The evidence is clear:
- Range-of-motion exercises should be initiated immediately to prevent contracture progression, performing them several times daily in all patients with spastic paraparesis 1
- Antispastic positioning and proper body alignment reduce reflex hyperexcitability and prevent fixed contractures—the opposite effect of rigid immobilization 1, 2
- Stretching programs and splinting maintain joint mobility, which differs fundamentally from static immobilization in a knee immobilizer 1
The Correct Approach to Contractures and Spasticity
Non-Pharmacological Management (First-Line)
Start with active interventions that maintain mobility:
- Implement immediate range-of-motion exercises multiple times daily 1
- Apply dynamic splinting (not static immobilization) to maintain joint mobility while allowing controlled movement 1
- Use serial casting only for established contractures that interfere with function—this involves progressive repositioning, not static immobilization 1
Pharmacological Management
For generalized spasticity:
- Baclofen is the preferred first-line oral agent, particularly effective for flexor spasms and pain, starting at 5 mg three times daily 1, 2
- Tizanidine is FDA-approved and specifically recommended for chronic stroke patients 1, 3
- Dantrolene serves as an alternative oral agent 1
For focal spasticity:
- Botulinum toxin injections are strongly preferred over oral medications for specific muscle groups causing contractures 1, 3, 4
- Early botulinum toxin treatment reduces spasticity and slows contracture formation for approximately 12 weeks 4
Surgical Options for Severe Cases
When conservative measures fail:
- Surgical correction (hamstring release, tendon lengthening, capsular release) is indicated for severe contractures restricting movement or causing pain 1, 5, 6
- Intrathecal baclofen via programmable pump for refractory spasticity, with >80% of patients showing improvement in muscle tone 1, 2
Critical Pitfalls to Avoid
Do not immobilize joints in patients with spasticity or contractures—this accelerates contracture development and increases reflex hyperexcitability 1, 2. The only exception is knee-high devices for specific conditions like Charcot neuroarthropathy, which involves foot/ankle immobilization for fracture healing, not spasticity management 7.
Avoid benzodiazepines during recovery phases, as they impair neurological recovery and cause excessive sedation 1, 2, 3.
Monitor closely for muscle weakness when initiating baclofen therapy, as this could impair residual function 2.